Acute dental infections managed in an outpatient parenteral antibiotic program setting: prospective analysis and public health implications.

BACKGROUND: The number of Acute Dental Infections (ADI) presenting for emergency department (ED) care are steadily increasing. Outpatient Parenteral Antibiotic Therapy (OPAT) programs are increasingly utilized as an alternative cost-effective approach to the management of serious infectious diseases but their role in the management of severe ADI is not established. This study aims to address this knowledge gap through evaluation of ADI referrals to a regional OPAT program in a large Canadian center. METHODS: All adult ED and OPAT program ADI referrals from four acute care adult hospitals in Calgary, Alberta, were quantified using ICD diagnosis codes in a regional reporting system. Citywide OPAT program referrals were prospectively enrolled over a five-month period from February to June 2014. Participants completed a questionnaire and OPAT medical records were reviewed upon completion of care. RESULTS: Of 704 adults presenting to acute care facilities with dental infections during the study period 343 (49%) were referred to OPAT for ADI treatment and 110 were included in the study. Participant mean age was 44 years, 55% were women, and a majority of participants had dental insurance (65%), had seen a dentist in the past six months (65%) and reported prior dental infections (77%), 36% reporting the current ADI as a recurrence. Median length of parenteral antibiotic therapy was 3 days, average total course of antibiotics was 15-days, with a cumulative 1326 antibiotic days over the study period. There was no difference in total duration of antibiotics between broad and narrow spectrum regimes. Conservative cost estimate of OPAT care was $120,096, a cost savings of $597,434 (83%) compared with hospitalization. CONCLUSIONS: ADI represent a common preventable cause of recurrent morbidity. Although OPAT programs may offer short-term cost savings compared with hospitalization, risks associated with extended antibiotic exposures and delayed definitive dental management must also be gauged.

Hospital ward design and prevention of hospital-acquired infections: A prospective clinical trial.

BACKGROUND: Renovation of a general medical ward provided an opportunity to study health care facility design as a factor for preventing hospital-acquired infections. OBJECTIVE: To determine whether a hospital ward designed with predominantly single rooms was associated with lower event rates of hospital-acquired infection and colonization. METHODS: A prospective controlled trial with patient allocation incorporating randomness was designed with outcomes on multiple 'historic design' wards (mainly four-bed rooms with shared bathrooms) compared with outcomes on a newly renovated 'new design' ward (predominantly single rooms with private bathrooms). RESULTS: Using Poisson regression analysis and adjusting for time at risk, there were no differences (P=0.18) in the primary outcome (2.96 versus 1.85 events/1000 patient-days, respectively). After adjustment for age, sex, Charlson score, admitted from care facility, previous hospitalization within six months, isolation requirement and the duration on antibiotics, the incidence rate ratio was 1.44 (95% CI 0.71 to 2.94) for the new design versus the historic design wards. A restricted analysis on the numbers of events occurring in single-bed versus multibed wings within the new design ward revealed an event incidence density of 1.89 versus 3.47 events/1000 patient-days, respectively (P=0.18), and an incidence rate ratio of 0.54 (95% CI 0.15 to 1.30). CONCLUSIONS: No difference in the incidence density of hospital-acquired infections or colonizations was observed for medical patients admitted to a new design ward versus historic design wards. A restricted analysis of events occurring in single-bed versus multibed wings suggests that ward design warrants further study.

HISTORIQUE: La rénovation d'une unité d'hospitalisation générale a permis d'étudier la conception des établissements de santé comme facteur pour prévenir les infections nosocomiales. OBJECTIF: Déterminer si une unité d'hospitalisation contenant surtout des chambres individuelles s'associe à un taux plus faible d'infections nosocomiales et de colonisations. MÉTHODOLOGIE: Un essai prospectif contrôlé avec répartition aléatoire des patients a permis de comparer les résultats dans diverses « anciennes ¼ unités (surtout des chambres à quatre lits dont les toilettes sont partagées) à ceux dans des unités « rénovées ¼ (surtout des chambres individuelles dotées de toilettes individuelles). RÉSULTATS: D'après l'analyse de régression de Poisson et après rajustement en fonction du temps à risque, il n'y avait pas de différences (P=0,18) dans les résultats primaires (2,96 par rapport à 1,85 événements sur 1 000 patients-jour, respectivement). Après rajustement compte tenu de l'âge, du sexe, de l'indice de Charlson, de l'admission en provenance d'un établissement de soins, d'une hospitalisation dans les six mois précédents, de la nécessité d'isolement et de la durée de l'antibiothérapie, le ratio d'incidence était de 1,44 (95 % IC 0,71 à 2,94) pour les nouvelles chambres par rapport aux anciennes. Une analyse restreinte du nombre d'événements qui se produisent dans les nouvelles unités de chambres individuelles plutôt que de chambres communes a révélé une densité d'incidence de 1,89 par rapport à 3,47 événements sur 1 000 patients-jour, respectivement (P=0,18), et un ratio d'incidence de 0,54 (95 % IC 0,15 à 1,30). CONCLUSIONS: Il n'y avait pas de différence dans la densité d'incidence des infections nosocomiales ou des colonisations chez les patients admis dans une nouvelle unité plutôt qu'une ancienne. D'après une analyse restreinte des événements qui se produisent dans des unités de chambres individuelles plutôt que de chambres communes, la conception des unités devrait faire l'objet d'études plus approfondies.

Central venous catheter-associated bloodstream infections occurring in Canadian intensive care units: A six-month cohort study.

OBJECTIVE: To determine the rate and risk factors associated with central venous catheter (CVC)-associated bloodstream infections (BSIs) in Canadian intensive care units (ICUs). DESIGN: A prospective, active six-month cohort with a nested case-control study. SETTING: Forty-one ICUs located in 19 Canadian hospitals. METHODS: Data were collected using a standardized format on all CVCs and patients when a CVC was inserted for more than 48 h. Results of microbiological studies and therapeutic interventions were recorded when a BSI occurred. RESULTS: There were 182 BSIs from 3696 CVC insertions in 2531 patients. Coagulase-negative staphylococci were responsible for 73% of the BSIs. Mean rates of CVC-associated BSIs per 1000 CVC days were 6.9, 6.8 and 5.0 in adult, neonatal and pediatric ICUs, respectively. Significant factors associated with BSI included duration of CVC insertion (OR=1.2, 95% CI 1.1 to 1.3), receiving total parenteral nutrition (OR=4.1, 95% CI 1.2 to 14.3) and having one or more CVCs (OR=3.1, 95% CI 1.5 to 6.5). In the case-control study, 80% of the variance in a backward elimination logistic regression analysis was explained by duration of CVC insertion (OR=1.2 per day), receiving chemotherapy (OR=6.1), more than one CVC insertion during the study (OR=3.5), insertion of a CVC with two or more lumens (OR=2.3), using the CVC to administer total parenteral nutrition (OR=1.6) and having a surgical wound other than a clean wound (OR=1.6). CONCLUSION: The present study identified risk factors explaining 80% of the variance associated with BSIs and is one of the largest reports on the rate of CVC-associated BSIs occurring in the ICU setting.

Incidence of bloodstream infection in multicenter inception cohorts of hemodialysis patients.

OBJECTIVE: To assess incidence of and identify risk factors for bloodstream infection in patients starting hemodialysis or starting a new means of vascular access for hemodialysis. METHOD: Two cohorts of patients, 1 initiating hemodialysis (new patients) and a 1:1 matching group of patients continuing hemodialysis but starting a new vascular access (continuing patients), were enrolled from 9 Canadian hemodialysis units and followed for 6 months. Bloodstream infection was defined using established criteria. A nested case-control study was carried out, using as cases those cohort patients diagnosed with infection. Each case was matched with a control having the same means of access and new or continuing status. RESULTS: A total of 527 patients (258 new, 269 continuing), were recruited and underwent 31,268 hemodialysis procedures during this 6-month follow-up. There were 96 bloodstream infections in 93 patients (11.97/10,000 days, 28.81/10,000 hemodialysis procedures), yielding a relative risk of infection of 3.33 (95% CI, 2.12-5.24) for patients with a previous bloodstream infection and 1.56 (95% CI, 1.02-2.38) for patients continuing hemodialysis by a new means of access. Survival analysis revealed that compared to arteriovenous fistula vascular access, the relative risk of bloodstream infection in patients was 1.47 (95% CI, 0.36-5.96) for arteriovenous grafts, 8.49 (95% CI, 3.03-23.78) for cuffed central venous catheters, and 9.87 (95% CI, 3.46-28.20) for uncuffed central venous catheters. The regression model of the case-control study identified earlier bloodstream infection (OR, 6.58), poor patient hygiene (OR, 3.48), and superficial access-site infection (OR, 4.36) as additional risk factors. CONCLUSION: During the first 6 months there is a high rate of bloodstream infection in patients starting hemodialysis either for the first time or by a new means of vascular access. Previous hemodialysis bloodstream infection and continuing hemodialysis by a new means of vascular access are markers for an increased risk of infection, as is poor patient hygiene. Central venous catheter vascular access, whether cuffed or uncuffed, has a much higher infection risk. In this study, there was no difference in infection rate between cuffed and uncuffed central catheters.

Prospective surveillance for primary bloodstream infections occurring in Canadian hemodialysis units.

OBJECTIVE: Bloodstream infections are a major cause of morbidity and mortality in patients receiving long-term hemodialysis. We wanted to determine the incidence of hemodialysis-related bloodstream infections in Canadian centers participating in the Canadian Nosocomial Infection Surveillance Program. METHODS: Prospective surveillance for hemodialysis-related bloodstream infections was performed in 11 centers during a 6-month period. Bloodstream infections were defined by published criteria. Hemodialysis denominators included the number of dialysis procedures, the number of patient-days on dialysis, and the frequencies of different types of vascular access. RESULTS: There were 184 bloodstream infections in 133,158 dialysis procedures (1.4 per 1,000) and 316,953 patient-days (0.6 per 1,000). Hemodialysis access through arteriovenous (AV) fistulae was associated with the lowest risk for bloodstream infection (0.2 per 1,000 dialysis procedures). The relative risk for infection was 2.5 with AV graft access, 15.5 with cuffed and tunneled central venous catheter (CVC) access, and 22.5 with uncuffed CVC access (P < .001). There was marked variation among the 11 centers in the means of vascular access used for hemodialysis. Significant variation in infection rates was observed among the centers when controlling for types of access. CONCLUSIONS: There was a hierarchy of risk of hemodialysis-related bloodstream infection according to type of vascular access. There was significant variation in the type of vascular access being used among the Canadian hemodialysis centers, and also variation in access-specific infection rates between centers.